Fast forward close to a year, and the dramatic increase in teen e-cigarette use has come into much sharper focus, thanks to the recent publication of two nationwide surveys tracking youth tobacco prevalence.

And, the somewhat tempered early warnings of the NAS report have been replaced by a full-throated call to arms from health officials vowing to address the seismic increase in vaping among youth in the U.S.

"The bottom line is we have never seen use of any (monitored) substance by America's young people rise this rapidly. This is an unprecedented challenge," said Health and Human Services Secretary Alex Azar at a Dec. 18 press conference.

"We are at risk of a huge share of a whole generation developing an addiction to nicotine -- and that is not a future anyone wants for our country," he said.

Teen E-Cigarette Use Doubled in 2018

The Monitoring the Future Survey, funded by the National Institutes of Health and conducted by researchers at the University of Michigan, has been monitoring substance use by teens and young adults since 1975.

The latest findings from the annual survey, published in mid-December, showed that from 2017 to 2018, the rise in e-cigarette use by 10th and 12th graders was the largest single-year increase in use of a monitored substance ever recorded by the survey.

Among the main findings:

Current e-cigarette use among 12th graders nearly doubled during 2017 and 2018, from 11% to 21%, with more than one-fifth of high school seniors reporting vaping within the last 30 days

E-cigarette use also nearly doubled among 10th graders during the time period, with 16.1% reporting current use compared to 8.2% in 2017, and current vaping increased from 3.5% in 2017 to 6.1% in 2018 among 8th graders

The increase translates to about 1.3 million more adolescents using e-cigarettes in 2018

Those results mirrored data from the federal government's latest National Youth Tobacco Survey (NYTS), published a month earlier, that found a 78% increase in high school student e-cigarette use from 2017 to 2018 and an almost 50% increase in current use among middle school students.

"These data shock my conscience," FDA Commissioner Scott Gottlieb, MD, said Nov. 15 at a press conference held to announce new restrictions on the sale and marketing of e-cigarettes and conventional cigarettes designed to address what the FDA commissioner has repeatedly referred to as the epidemic of teen e-cigarette use.

FDA Announced Action Plan

Gottlieb said the 2018 survey data on youth vaping were all the more surprising because surveys in 2016 had found use of all tobacco products, including conventional and electronic cigarettes, had declined among U.S. teens.

"What I did not predict was that in 2018, youth use of e-cigarettes and other electronic nicotine delivery systems (ENDS) products would become an epidemic," he said at the news conference last month.

Gottlieb vowed to take immediate steps designed to restrict access by minors. Those actions include banning the sale of flavored e-cigarettes, with the exception of mint, menthol, and tobacco, from sales at convenience stores and other retail establishments that are not age-restricted; tightening age-verification requirements for the sale of e-cigarettes online; and banning e-cigarette marketing that could appeal to kids.

The FDA commissioner said he was prepared to take more drastic action if the imposed policy changes did not reverse youth usage trends, including "eliminating any application enforcement discretion to any currently marketed ENDS product."

That would effectively remove all such products from the marketplace, he said.

"At this time, I am not proposing this route, as I don't want to foreclose opportunities for currently addicted adult smokers," he said.

Indeed, throughout the year, Gottlieb made clear his intention to make a safe space for e-cigarettes as smoking-cessation tools, repeatedly stating that vaping is safer than cigarette smoking and that, while prescription cessation products are preferable, smokers who wish to substitute e-cigarettes should have that option.

Juul Seen Driving E-Cig Epidemic

In a rare advisory issued in mid-December, U.S. Surgeon General Jerome Adams, MD, officially declared youth vaping an epidemic. Like Gottlieb and other health officials, he singled out the e-cigarette brand Juul as a big part of the problem.

He noted that Juul sales increased by 600% from 2016 to 2017. The cartridge e-cigarettes, which resemble USB flash drives, are wildly popular among teens.

The brand's nicotine content is also quite high, with a single cartridge or pod containing as much nicotine as a pack of 20 regular cigarettes. Juul also uses salts instead of free nicotine, which allows nicotine to be absorbed more readily in the lungs.

"This is of particular concern for young people, because it could make it easier for them to initiate the use of nicotine through these products and also could make it easier to progress to regular e-cigarette use and nicotine dependence," Adams said, adding that in one survey, two-thirds of teen and young adult Juul users did not know the product always contained nicotine.

Manufacturer Juul Labs has long maintained that the company markets its products solely for use by adult smokers who want a safer nicotine delivery alternative than combustible cigarettes.

The company's website notes that Juul was founded "with the goal of improving the lives of the world's one billion adult smokers."

In a press statement, Juul Labs CEO Kevin Burns acknowledged that many would view Altria's $12.8 billion investment in the e-cigarette company with skepticism, but he contended that "this partnership could help accelerate our success switching adult smokers."

In an interview with MedPage Today, Campaign for Tobacco-Free Kids CEO Matthew Myers said the merger means Juul Labs' claim to be promoting public health are no longer credible.

"This merger combines the skills of the two companies that have probably done more to introduce nicotine to our nation's kids than any other," he said.

Myers said the FDA's actions to address youth e-cigarette use, while well meaning, do not go far enough. He was especially critical of the decision to delay premarket review of e-cigarettes, which has allowed new products to enter the market without regulation.

"Immediately after Juul's success, almost every other e-cigarette company changed their product to mimic its delivery system," Myer noted. "I just don't understand why the FDA has not taken a stronger stand to keep these products off the market."

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